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Lin PT, Hseu SS, Fuh JL, Lirng JF, Chen SP, Chen WT, Wang SJ, Wang YF. Sex differences in the clinical manifestations and treatment outcomes in a large cohort of spontaneous intracranial hypotension. Headache 2024. [PMID: 39221780 DOI: 10.1111/head.14816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To determine sex differences in clinical profiles and treatment outcomes in patients with spontaneous intracranial hypotension. BACKGROUND Spontaneous intracranial hypotension is associated with considerable functional disability and potentially fatal complications, and it is uncertain whether males and females should be managed differently. METHODS This was a cohort study of consecutive patients with spontaneous intracranial hypotension enrolled from a medical center. Medical records and imaging findings were reviewed. The outcome of treatment responses to epidural blood patches and risks of subdural hematoma were measured. RESULTS In total, 442 patients with spontaneous intracranial hypotension (165 males, 277 females) were included in the analysis. Males were more likely to have a delayed (>30 days) initial presentation than females (32.1% [53/165] vs. 19.9% [55/277], p = 0.004), and males were less likely to have nausea (55.8% [92/165] vs. 67.1% [186/277], p = 0.016), vomiting (43.0% [71/165] vs. 54.2% [150/277], p = 0.024), photophobia (9.7% [16/165] vs. 17.0% [47/277], p = 0.034), and tinnitus (26.7% [44/165] vs. 39.7% [110/277], p = 0.005) compared with females despite comparable radiologic findings. Among the 374 patients treated with epidural blood patches, males were more likely to be nonresponders to the first epidural blood patch (58.0% [80/138] vs. 39.0% [92/236], OR = 2.2, 95% CI = 1.4-3.3, p < 0.001). Males were at a higher risk of having subdural hematoma (29.7% [49/165] vs. 10.8% [30/277], OR = 3.5, 95% CI = 2.1-5.8, p < 0.001). Among patients with subdural hematoma, males had greater thickness (12.8 ± 4.3 vs. 8.1 ± 5.9 mm, p < 0.001) and were more likely to receive surgical drainage (55.1% [27/49] vs. 10.0% [3/30], OR = 11.0, 95% CI = 3.0-41.3, p < 0.001) than females. CONCLUSION In the present study, spontaneous intracranial hypotension in males was characterized by a delayed presentation, poorer response to the first epidural blood patch, and a higher risk of subdural hematoma. Caution should be exercised in the management of males with spontaneous intracranial hypotension. The generalizability of the findings needs to be further confirmed.
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Affiliation(s)
- Po-Tso Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Shya Hseu
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Ta Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Ministry of Health and Welfare Keelung Hospital, Keelung, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Uppal V, Russell R, Sondekoppam RV, Ansari J, Baber Z, Chen Y, DelPizzo K, Dirzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo C, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group. Reg Anesth Pain Med 2024; 49:471-501. [PMID: 37582578 DOI: 10.1136/rapm-2023-104817] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. METHODS Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach. RESULTS Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence. CONCLUSIONS These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California, USA
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Dan Sebastian Dirzu
- Anesthesia and Intensive Care, Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter G Kranz
- Depatement of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa Leffert
- Department of Anesthesiology, Yale New Haven Health System; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grace Lim
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics & Gynecology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Clara Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London North West Healthcare NHS Trust, Harrow, London, UK
| | - Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital - Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Stephen E Rodriguez
- Department of Anesthesia, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Herman Sehmbi
- Department of Anesthesia, Western University, London, Ontario, Canada
| | - Manuel C Vallejo
- Departments of Medical Education, Anesthesiology, Obstetrics & Gynecology, West Virginia University, Morgantown, West Virginia, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Northeast Ohio Medical University, Rootstown, Ohio, USA
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
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Schievink WI, Maya MM, Taché RB, Walker CT. Pediatric post-dural puncture headache and paraplegia. Headache 2024; 64:865-868. [PMID: 38860510 DOI: 10.1111/head.14749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
A cerebrospinal fluid (CSF) leak developed in a 14-year-old girl and a 12-year-old boy following a diagnostic lumbar puncture. Two days and sixteen years later, respectively, paraplegia developed due to a functional disorder. Imaging revealed an extensive extradural CSF collection in both patients and digital subtraction myelography was required to pinpoint the exact site of a ventral dural puncture hole where the lumbar spinal needle had gone "through and through" the dural sac. The CSF leak was complicated by cortical vein thrombosis in one patient. Both patients underwent uneventful surgical repair of the ventral dural puncture hole with prompt resolution of the paraplegia. Iatrogenic ventral CSF leaks may become exceptionally long standing and may be complicated by paraplegia on a functional basis both in the acute and chronic phases.
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Affiliation(s)
- Wouter I Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marcel M Maya
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rachelle B Taché
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Corey T Walker
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Osawa I, Mitsufuji T, Nagawa K, Hara Y, Yamamoto T, Araki N, Kozawa E. Comparing 2-dimensional versus 3-dimensional MR myelography for cerebrospinal fluid leak detection. Eur J Radiol Open 2024; 12:100565. [PMID: 38699593 PMCID: PMC11063600 DOI: 10.1016/j.ejro.2024.100565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
Purpose We compared cerebrospinal fluid (CSF) leak conspicuity and image quality as visualized using 3D versus 2D magnetic resonance (MR) myelography in patients with spinal CSF leaks. Methods Eighteen patients underwent spinal MR imaging at 3 Tesla. Three board-certified radiologists independently evaluated CSF leak conspicuity and image quality on a 4-point scale; the latter assessed by scoring fat suppression, venous visualization, and severity of CSF flow artifacts. Additionally, the evaluators ranked the overall performances of 2D versus 3D MR myelography upon completing side-by-side comparisons of CSF leak conspicuity. Inter-reader agreement was determined using the Gwet's AC1. Results The quality of 3D MR myelography images was significantly better than that of 2D MR myelography with respect to CSF leak conspicuity (mean scores: 3.3 vs. 1.9, p < 0.0001) and severity of CSF flow artifacts on the axial view (mean scores: 1.0 vs. 2.5, p = 0.0001). Inter-reader agreement was moderate to almost perfect for 2D MR myelography (AC1 = 0.55-1.00), and almost perfect for 3D MR myelography (AC1 = 0.85-1.00). Moreover, 3D MR myelography was judged to be superior to 2D acquisition in 78 %, 83 %, and 83 % of the samples per readers 1, 2 and 3, respectively; the inter-reader agreement was almost perfect (AC1: reader 1 vs. 2; 0.98, reader 2 vs. 3; 0.96, reader 3 vs. 1; 0.98). Conclusion CSF leaks are more conspicuous when using 3D MR myelography than when using its 2D counterpart; therefore, the former is more reliable for identifying such leaks.
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Affiliation(s)
- Iichiro Osawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Takashi Mitsufuji
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Keita Nagawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Yuki Hara
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Toshimasa Yamamoto
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Nobuo Araki
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Eito Kozawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
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Kaivola S, Martola J, Väänänen A. Extensive epidural spread of cerebrospinal fluid displacing the spinal cord after an inadvertent dural puncture in an obstetric patient. Int J Obstet Anesth 2024; 57:103960. [PMID: 38155054 DOI: 10.1016/j.ijoa.2023.103960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 09/21/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023]
Abstract
We report a rare complication of an inadvertent dural puncture in an obstetric patient. A 24-year-old healthy primipara had a difficult neuraxial labor analgesia insertion. Subsequently she developed severe back pain and started having 'electric shock'-like sensations radiating from the spine to the lower extremities, raising a suspicion of a vertebral canal hematoma. Topping up the epidural for emergency cesarean section was unsuccessful and the surgery was done under general anesthesia. Subsequent emergency magnetic resonance imaging (MRI) of the spine showed no signs of bleeding but her symptoms persisted, and a repeat MRI of the spine ultimately revealed substantial epidural fluid collection extending from the cervical level to the lower thoracic spine, with signs of intracranial hypotension in the MRI of the brain. The dorsal dura and the spinal cord were displaced anteriorly and there was a slight compression of the spinal cord. Repeated neuro-imaging led to the diagnosis of a previously unrecognized inadvertent dural puncture and extensive cerebrospinal fluid spread within the epidural space, causing a sensory phenomenon in the spine and lower extremities known as Lhermitte's sign. An epidural blood patch relieved the symptoms and restored cerebrospinal fluid surrounding the spinal cord, demonstrated at follow-up MRI. In conclusion, a repeated MRI of the spine and brain should be performed if the patient has persistent symptoms in the back or extremities, in order to detect a possible undiagnosed dural puncture complicated by the potentially serious consequences of extradural fluid leakage.
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Affiliation(s)
- S Kaivola
- Department of Anesthesiology and Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland.
| | - J Martola
- Department of Radiology, Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A Väänänen
- Department of Anesthesiology and Intensive Care, Helsinki University Hospital, Women's Hospital, Helsinki, Finland
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Bishop R, Chen A, Yates WD, Fowler J, Macres S. Update and Advances on Post-dural Puncture Headache. Adv Anesth 2023; 41:71-85. [PMID: 38251623 DOI: 10.1016/j.aan.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
This document provides an overview of post-dural puncture headache (PDPH), covering its historical perspective, anatomy and physiology of cerebrospinal fluid (CSF), pathophysiology, risk factors, diagnosis, and treatment options. PDPH is a common complication of dural puncture, characterized by a postural headache due to CSF leakage. The understanding of CSF and dural anatomy has evolved over time, leading to advancements in diagnosing and managing PDPH. Treatment options range from conservative measures to epidural blood patch, intrathecal catheter, and regional techniques like sphenopalatine ganglion block and greater occipital nerve block. Further research is needed to optimize treatment approaches and improve patient outcomes.
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Affiliation(s)
- Robert Bishop
- Department of Anesthesiology & Pain Medicine, UC Davis Medical Center, 4150 V Street, PSSB Suite 1200, Sacramento, CA 95817, USA.
| | - Amy Chen
- Department of Anesthesiology & Pain Medicine, UC Davis Medical Center, 4150 V Street, PSSB Suite 1200, Sacramento, CA 95817, USA
| | - William Derois Yates
- Department of Anesthesiology & Pain Medicine, UC Davis Medical Center, 4150 V Street, PSSB Suite 1200, Sacramento, CA 95817, USA
| | - Julie Fowler
- Department of Anesthesiology & Pain Medicine, UC Davis Medical Center, 4150 V Street, PSSB Suite 1200, Sacramento, CA 95817, USA
| | - Stephen Macres
- Department of Anesthesiology & Pain Medicine, UC Davis Medical Center, 4150 V Street, PSSB Suite 1200, Sacramento, CA 95817, USA
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Taraskiewicz D, Sheeran J, De Marco P, Tiouririne M, Elkassabany N. Etiology, management, and sequela of postdural puncture headache. Curr Opin Anaesthesiol 2023; 36:565-571. [PMID: 37552012 DOI: 10.1097/aco.0000000000001286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE The purpose of this article is to provide readers with a concise overview of the cause, incidence, treatment of, and sequalae of postdural puncture headaches (PDPH). Over the past 2 years, much data has been published on modifiable risk factors for PDPH, treatments for PDPH, and sequalae of PDPH particularly long-term. RECENT FINDINGS There is emerging data about how modifiable risk factors for PDPH are not as absolute as once believed. There have been several new meta-analysis and clinical trials published, providing more data about effective therapies for PDPH. Significantly, much recent data has come out about the sequalae, particularly long-term of dural puncture. SUMMARY Emerging evidence demonstrates that in patients who are at low risk of PDPH, needle type and gauge may be of no consequence in a patient developing a PDPH. Although epidural blood patch (EBP) remains the gold-standard of therapy, several other interventions, both medical and procedural, show promise and may obviate the need for EBP in patients with mild-moderate PDPH. Patients who endure dural puncture, especially accidental dural puncture (ADP) are at low but significant risk of developing short term issues as well as chronic pain symptoms.
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Affiliation(s)
- Daniel Taraskiewicz
- Department of Anesthesiology, University of Virginia, School of Medicine, Hospital of the University of Virginia, Virginia, USA
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Uppal V, Russell R, Sondekoppam R, Ansari J, Baber Z, Chen Y, DelPizzo K, Dîrzu DS, Kalagara H, Kissoon NR, Kranz PG, Leffert L, Lim G, Lobo CA, Lucas DN, Moka E, Rodriguez SE, Sehmbi H, Vallejo MC, Volk T, Narouze S. Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report. JAMA Netw Open 2023; 6:e2325387. [PMID: 37581893 DOI: 10.1001/jamanetworkopen.2023.25387] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Importance Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking. Objective To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH. Evidence Review With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach. Findings After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified. Conclusions and Relevance Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.
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Affiliation(s)
- Vishal Uppal
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robin Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, England
| | - Rakesh Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City
| | - Jessica Ansari
- Anesthesia Department, Stanford Health Care, Stanford, California
| | - Zafeer Baber
- Department of Anesthesiology and Perioperative Medicine, Newton-Wellesley Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Yian Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Kathryn DelPizzo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Dan Sebastian Dîrzu
- Department of Anaesthesia and Intensive Care, Emergency County Hospital, Cluj-Napoca, Romania
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Narayan R Kissoon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Peter G Kranz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Lisa Leffert
- Yale University School of Medicine, Yale New Haven Hospital and Bridgeport Hospital, New Haven, Connecticut
| | - Grace Lim
- Department of Anesthesiology and Perioperative Medicine, Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Magee Hospital, Pittsburgh, Pennsylvania
| | - Clara A Lobo
- Anesthesiology Institute, Interventional Pain Medicine Department, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Dominique Nuala Lucas
- Department of Anaesthesia, London Northwest University Healthcare NHS Trust, London, England
| | - Eleni Moka
- Anaesthesiology Department, Creta Interclinic Hospital-Hellenic Healthcare Group, Heraklion, Crete, Greece
| | | | - Herman Sehmbi
- Department of Anesthesia, University of Western Ontario, London, Ontario, Canada
| | - Manuel C Vallejo
- Medical Education, Anesthesiology, Obstetrics and Gynecology, West Virginia University, Morgantown
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Saarbrücken, Germany
| | - Samer Narouze
- Rootstown and Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio
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Rodriguez-Camacho M, Guirado-Ruiz PA, Barrero-Hernández FJ. Risk factors for post-dural puncture headache. Rev Clin Esp 2023:S2254-8874(23)00061-9. [PMID: 37169081 DOI: 10.1016/j.rceng.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/19/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Post-dural puncture headache (PDPH) is the most common complication following lumbar puncture. However, its incidence varies according to the series consulted. Different factors associated with its onset have been identified. OBJECTIVES The purpose of this study is to determine the incidence of PDPH and to identify predisposing factors for its appearance. METHOD Prospective, descriptive study in 57 patients who underwent lumbar puncture procedures. To this end, variables associated with patient-related risk factors, clinical and procedural factors with the presence of PDPH were analysed. The incidence of PDPH was 38.6% and factors associated with onset included young age and previous history of headache. RESULTS The incidence of PDPH was higher in women and presented greater intensity in this group, though studies with a larger sample size would need to be conducted. CONCLUSIONS We must bear in mind the factors associated with the appearance of PDPH, which include: young age, history of headache, and the perception of procedural difficulty, to better inform patients and optimise the techniques used.
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Affiliation(s)
| | | | - Francisco Javier Barrero-Hernández
- Servicio de Neurología del Hospital Universitario Clínico San Cecilio de Granada; Departamento de Medicina, Facultad de Medicina, Universidad de Granada; Instituto de Investigación Biosanitaria, ibs, Granada.
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10
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Kawahara T, Atsuchi M, Arita K, Fujio S, Higa N, Hanaya R. Paravertebral Cerebrospinal Fluid Exudation in Young Women with Postdural Puncture Headache: A Hypothetical Interpretation based on Anatomical Study on Intervertebral Foramen. Asian J Neurosurg 2023; 18:117-124. [PMID: 37056874 PMCID: PMC10089746 DOI: 10.1055/s-0043-1763526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Background Postdural puncture headache (PDPH) is defined as a prolonged orthostatic headache secondary to a lumbar puncture. The mechanism underlying this unpleasant complication and the reasons explaining its higher incidence in the young are not well understood. Here, we speculate on the mechanisms underlying PDPH based on spinal magnetic resonance imaging (MRI) in patients with PDPH and an anatomical study on the size of the intervertebral foramen.
Methods Brain and spinal MRI findings were examined in two young women with PDPH. The relationship between age and size of the intervertebral foramen on computed tomography was assessed in 25 female volunteers (22–89 years old) without spinal disease.
Results The causative interventions leading to PDPH were epidural anesthesia for painless delivery in a 28-year-old woman and lumbar puncture for examination of the cerebrospinal fluid (CSF) in a 17-year-old woman. These two patients developed severe orthostatic hypotension following the procedure. Brain MRI showed signs of intracranial hypotension, including subdural effusion, in one patient, but no abnormality in the other. Spinal MRI revealed an anterior shift of the spinal cord at the thoracic level and CSF exudation into the paravertebral space at the lumbar level. Treatment involving an epidural blood patch in one patient and strict bed rest with sufficient hydration in the second led to improvement of symptoms and reduction of paravertebral CSF exudation. The size of the intervertebral foramen at the L2–3 level in the 25 volunteers showed a decrease in an age-dependent manner (Spearman's rho −0.8751, p < 0.001).
Conclusion We suggest that CSF exudation from the epidural space of the vertebral canal to the paravertebral space through the intervertebral foramen, which is generally larger in the younger population, is the causative mechanism of PDPH.
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Lin PT, Wang YF, Hseu SS, Fuh JL, Lirng JF, Wu JW, Chen ST, Chen SP, Chen WT, Wang SJ. The SIH-EBP Score: A grading scale to predict the response to the first epidural blood patch in spontaneous intracranial hypotension. Cephalalgia 2023; 43:3331024221147488. [PMID: 36786320 DOI: 10.1177/03331024221147488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND To develop and validate an easy-to-use scoring system to predict the response to the first epidural blood patching in patients with spontaneous intracranial hypotension. METHODS This study recruited consecutive patients with spontaneous intracranial hypotension receiving epidural blood patching in a tertiary medical center, which were chronologically divided into a derivation cohort and a validation cohort. In the derivation cohort, factors associated with the first epidural blood patching response were identified by using multivariable logistic regression modeling. A scoring system was developed, and the cutoff score was determined by using the receiver operating characteristic curve. The findings were verified in an independent validation cohort. RESULTS The study involved 280 patients in the derivation cohort and 78 patients in the validation cohort. The spontaneous intracranial hypotension-epidural blood patching score (range 0-5) included two clinical variables (sex and age) and two radiological variables (midbrain-pons angle and anterior epidural cerebrospinal fluid collections). A score of ≥3 was predictive of the first epidural blood patching response, which was consistent in the validation cohort. Overall, patients who scored ≥3 were more likely to respond to the first epidural blood patching (odds ratio = 10.3). CONCLUSION For patients with spontaneous intracranial hypotension-epidural blood patching score ≥3, it is prudent to attempt at least one targeted epidural blood patching before considering more invasive interventions.
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Affiliation(s)
- Po-Tso Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Shya Hseu
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Anaesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jr-Wei Wu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Ting Chen
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Ta Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Ministry of Health and Welfare Keelung Hospital, Keelung, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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12
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Diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension: a systematic review and meta-analysis. Eur Radiol 2022; 32:7843-7853. [PMID: 35538263 DOI: 10.1007/s00330-022-08845-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To investigate the pooled diagnostic yield of MR myelography in patients with newly diagnosed spontaneous intracranial hypotension (SIH). METHODS A literature search of the MEDLINE/PubMed and Embase databases was conducted until July 25, 2021, including studies with the following inclusion criteria: (a) population: patients with newly diagnosed SIH; (b) diagnostic modality: MR myelography or MR myelography with intrathecal gadolinium for evaluation of CSF leakage; (c) outcomes: diagnostic yield of MR myelography or MR myelography with intrathecal gadolinium. The risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. DerSimonian-Laird random-effects modeling was used to calculate the pooled estimates. Subgroup analysis regarding epidural fluid collection and meta-regression were additionally performed. RESULTS Fifteen studies with 643 patients were included. Eight studies used MR myelography with intrathecal gadolinium, and 11 used MR myelography. The overall quality of the included studies was moderate. The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) and that of MR myelography with intrathecal gadolinium was 83% (95% CI, 51-96%). There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium (p = 0.512). In subgroup analysis, the pooled diagnostic yield of the epidural fluid collection was 91% (95% CI, 84-94%). In meta-regression, the diagnostic yield was unaffected regardless of consecutive enrollment, magnet strength, or 2D/3D. CONCLUSIONS MR myelography had a high diagnostic yield in patients with SIH. MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium. KEY POINTS • The pooled diagnostic yield of MR myelography was 86% (95% CI, 80-91%) in patients with spontaneous intracranial hypotension. • There was no significant difference in pooled diagnostic yield between MR myelography and MR myelography with intrathecal gadolinium. • MR myelography is non-invasive and not inferior to MR myelography with intrathecal gadolinium.
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13
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Giagkou N, Spanou I, Mitsikostas DD. Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes. Expert Rev Neurother 2022; 22:815-827. [PMID: 36453212 DOI: 10.1080/14737175.2022.2152674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Headaches occur when cerebrospinal fluid (CSF) pressure drops following dural puncture or trauma or spontaneously. As the features of these headaches and their accompanying symptoms might not be typical, low CSF pressure headache syndromes, and spontaneous intracranial hypotension in particular, are often misdiagnosed and underdiagnosed. AREAS COVERED The aim of this narrative review is to summarize the most recent evidence regarding the clinical presentation and the diagnosis of low CSF pressure headache syndromes. EXPERT OPINION The clinical spectrum low CSF pressure headache syndromes varies significantly and key signs might be missing. Low CSF pressure headache syndromes should be included in the differential diagnosis of any case of refractory headache, even when the headache is not orthostatic, or there are normal neuroimaging findings, and/or lumbar puncture opening pressure is within normal limits. Future research should focus on controlled interventional studies on the treatment of low CSF pressure headache syndromes, which are currently lacking.
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Affiliation(s)
- Nikolaos Giagkou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Spanou
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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14
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Megalla M, Decilveo AP, McCunney RM, Ruoff M. Iatrogenic CSF Leak from CT Myelogram Leading to Cauda Equina Compression: A Case Report. J Orthop Case Rep 2022; 12:30-33. [PMID: 36873344 PMCID: PMC9983418 DOI: 10.13107/jocr.2022.v12.i09.3002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/29/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction Although magnetic resonance imaging (MRI) is the preferred imaging modality for diagnosing cauda equina syndrome (CES), computerized tomography (CT) myelogram may be used in patients who are unable to undergo MRI. When inserting the needle for CT myelogram, there is a risk of cerebrospinal fluid (CSF) leak, which theoretically could lead to CES. To the best of our knowledge, there are no reports of CT myelogram resulting in cauda equina compression. Case Report We report the case of a 38-year-old man who underwent surgical decompression for CES and developed an iatrogenic CSF leak from a pre-operative CT myelogram causing recurrent thecal sac compression requiring repeat surgery and dural repair. Conclusion Although CT myelogram may be used to aid in the diagnosis of CES, consideration should be given to the potential risk for causing a CSF leak and resultant thecal sac compression.
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Affiliation(s)
- Martinus Megalla
- Department of Orthopaedic Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Alexander P Decilveo
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Robert M McCunney
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Mark Ruoff
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
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Vikram VN, Roy Chowdhury S. Case of extensive cerebrospinal fluid leak postlumbar puncture in a paediatric patient with idiopathic intracranial hypertension. BMJ Case Rep 2022; 15:e246131. [PMID: 35487640 PMCID: PMC9058714 DOI: 10.1136/bcr-2021-246131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 11/03/2022] Open
Abstract
Lumbar punctures are frequently used in the diagnostic evaluation of central nervous system diseases such as infections, administration of medications such as chemotherapy and for reduction in intracranial pressure in cases of idiopathic intracranial hypertension. Cerebrospinal fluid (CSF) leak through a dural tear can result in temporary side effects such as headache (postlumbar puncture headache) and backache. Rarely, more severe side effects may occur with neurological deficits if there is an extensive CSF collection or epidural haematoma. However, the majority of these lesions can be managed conservatively.
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16
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Treatment, Outcome, and Relapse of Spontaneous and Nonspontaneous Cerebrospinal Fluid Leak. Brain Sci 2022; 12:brainsci12030340. [PMID: 35326296 PMCID: PMC8945904 DOI: 10.3390/brainsci12030340] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 02/05/2023] Open
Abstract
Cerebrospinal fluid (CSF) leak can be spontaneous or nonspontaneous. The management options include conservative treatments, blood patch, and surgical repairs. We compared clinical symptoms, image findings, management options, hospitalization, and relapse rates among different causes of CSF leaks. Eighty-one patients were recruited: 20 with spontaneous and 61 with nonspontaneous CSF leaks. Nonspontaneous causes included lumbar puncture, surgery, and trauma. Surgery sites comprised sphenoid, spine, skull base, and calvaria. Spontaneous CSF leak came from the sphenoid or spine. Age, gender, body mass index, initial symptoms, hospitalization, treatment courses, and recurrence rates showed no difference between the groups. The spontaneous group had higher CSF accumulations on their MRIs. MRI pachymeninge enhancement showed the highest sensitivity (78.6%) for intracranial hypotension. Meningitis occurred in 1/3 of sphenoid, skull base, and calvarian surgeries. Earlier reoperation was correlated with shorter hospitalization (r = 0.651), but the recurrence rates were similar. Longer intervals between surgery and CSF leak encouraged reoperation. Among the spontaneous spine and lumbar puncture-related CSF leaks, 57.1% of them responded to 4 days of conservative treatment. Among the trauma-related CSF leaks, 90.9% of them required surgical repair. The demographic data and symptoms were similar in various groups of CSF leak. The symptom onset durations and treatment strategies were different. However, the recurrence rates were similar.
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17
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Mill J, Patel V, Okonkwo O, Li L, Raife T. Erythrocyte sphingolipid species as biomarkers of Alzheimer's disease. J Pharm Anal 2022; 12:178-185. [PMID: 35573876 PMCID: PMC9073235 DOI: 10.1016/j.jpha.2021.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 06/08/2021] [Accepted: 07/13/2021] [Indexed: 01/25/2023] Open
Abstract
Diagnosing Alzheimer's disease (AD) in the early stage is challenging. Informative biomarkers can be of great value for population-based screening. Metabolomics studies have been used to find potential biomarkers, but commonly used tissue sources can be difficult to obtain. The objective of this study was to determine the potential utility of erythrocyte metabolite profiles in screening for AD. Unlike some commonly-used sources such as cerebrospinal fluid and brain tissue, erythrocytes are plentiful and easily accessed. Moreover, erythrocytes are metabolically active, a feature that distinguishes this sample source from other bodily fluids like plasma and urine. In this preliminary pilot study, the erythrocyte metabolomes of 10 histopathologically confirmed AD patients and 10 patients without AD (control (CTRL)) were compared. Whole blood was collected post-mortem and erythrocytes were analyzed using ultra-performance liquid chromatography tandem mass spectrometry. Over 750 metabolites were identified in AD and CTRL erythrocytes. Seven were increased in AD while 24 were decreased (P<0.05). The majority of the metabolites increased in AD were associated with amino acid metabolism and all of the decreased metabolites were associated with lipid metabolism. Prominent among the potential biomarkers were 10 sphingolipid or sphingolipid-related species that were consistently decreased in AD patients. Sphingolipids have been previously implicated in AD and other neurological conditions. Furthermore, previous studies have shown that erythrocyte sphingolipid concentrations vary widely in normal, healthy adults. Together, these observations suggest that certain erythrocyte lipid phenotypes could be markers of risk for development of AD.
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Affiliation(s)
- Jericha Mill
- Department of Chemistry, University of Wisconsin-Madison, Madison, WI, 53706, USA
| | - Vihar Patel
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53705, USA
| | - Ozioma Okonkwo
- Clinical Science Center, Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Lingjun Li
- Department of Chemistry, University of Wisconsin-Madison, Madison, WI, 53706, USA
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI, 53705, USA
- Corresponding author. School of Pharmacy and Department of Chemistry, University of Wisconsin-Madison, Madison, WI, 53705, USA.
| | - Thomas Raife
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53705, USA
- Corresponding author.
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18
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Recent Advances in Understanding of Alzheimer's Disease Progression through Mass Spectrometry-Based Metabolomics. PHENOMICS (CHAM, SWITZERLAND) 2022; 2:1-17. [PMID: 35656096 PMCID: PMC9159642 DOI: 10.1007/s43657-021-00036-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Alzheimer's disease (AD) is the leading cause of dementia in the aging population, but despite extensive research, there is no consensus on the biological cause of AD. While AD research is dominated by protein/peptide-centric research based on the amyloid hypothesis, a theory that designates dysfunction in beta-amyloid production, accumulation, or disposal as the primary cause of AD, many studies focus on metabolomics as a means of understanding the biological processes behind AD progression. In this review, we discuss mass spectrometry (MS)-based AD metabolomics studies, including sample type and preparation, mass spectrometry specifications, and data analysis, as well as biological insights gleaned from these studies, with the hope of informing future AD metabolomic studies.
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19
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Chen HC, Chai JW, Wu CC, Chen PL, Teng CL. Magnetic resonance imaging predicted the therapeutic response of patients with spinal cerebrospinal fluid leakage undergoing targeted epidural blood patch. Br J Radiol 2022; 95:20210841. [PMID: 34762485 PMCID: PMC8722244 DOI: 10.1259/bjr.20210841] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Most patients with spinal cerebrospinal fluid (CSF) leakage require an epidural blood patch (EBP); however, the response to treatment is varied. This study aimed to compare the MRI findings at follow-up between EBP effective and non-effective groups and to identify imaging findings that predict EBP treatment failure. METHODS We retrospectively reviewed 48 patients who received EBP treatment for spinal CSF leakage. These patients were stratified into two groups: EBP effective (n = 27) and EBP non-effective (n = 21) using the results of the 3 month MRI as the end point. RESULTS Compared to the EBP non-effective group, the patients in the EBP effective group had a lower spinal CSF leakage number (2.67 vs 12.48; p = 0.001), lower spinal epidural fluid accumulation levels (3.00 vs 7.48; p = 0.004), brain descend (11.11% vs 38.10%; p = 0.027), pituitary hyperemia (18.52% vs 57.14%; p = 0.007), and decreased likelihood of ≥three numbers of spinal CSF leakage (25.93% vs 90.48%; p = 0.001) in the post-EBP MRI. Clinical non-responsiveness (OR: 57.84; 95% CI: 3.47-972.54; p = 0.005) and ≥three numbers of spinal CSF leakage (OR: 15.13; 95% CI: 1.45-159.06; p = 0.023) were associated with EBP failure. Between these variables, ≥three numbers of spinal CSF leakage identified using the post-EBP MRI demonstrated greater sensitivity in predicting EBP failure compared to clinical non-responsiveness (90.48% vs 61.9%). CONCLUSION The number of spinal CSF leakage identified using the post-EBP MRI with a cut-off value of three is an effective predictor of EBP failure. ADVANCES IN KNOWLEDGE Compared to clinical responsiveness, the post-EBP MRI provided a more objective approach to predict the effectiveness of EBP treatment in patients with spinal CSF leakage.
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20
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D'Souza RS, Woods CD, Lee D, Kissoon N, Bendel M. Delayed Cutaneous Fluid Leakage after Fluoroscopic-Guided Epidural Steroid Injection. PAIN MEDICINE 2021; 22:3092-3095. [PMID: 33755154 DOI: 10.1093/pm/pnab108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Charonn D Woods
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Daewoong Lee
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Narayan Kissoon
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Markus Bendel
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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21
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Risk factors for nonresponsive hydration in patients with spinal cerebrospinal fluid leakage. BMC Neurol 2021; 21:427. [PMID: 34732159 PMCID: PMC8564966 DOI: 10.1186/s12883-021-02464-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spinal cerebrospinal fluid (CSF) leakage is frequently encountered clinically after lumbar puncture or spontaneous events. Although some patients recover without treatment or after intensive hydration, some require an epidural blood patch (EBP). The risks of nonresponsive hydration remain unknown. Therefore, we identified the risk factors for patients with spinal CSF leakage nonresponsive to hydration. METHODS We retrospectively reviewed patients diagnosed with spinal CSF leakage between January 2010 and March 2021. Clinical data, including patient age, sex, etiology, and radiological indications in magnetic resonance imaging, were compared between patients who were responsive and non-responsive to hydration. RESULTS Of the 74 patients with spinal CSF leakage, 25 were responsive to hydration and 49 required EBP. Patients who were nonresponsive to hydration were older (39.27 vs. 34.32 years, P = 0.01), had a higher percentage of spontaneous intracranial hypotension (93.88% vs. 68.00%, P = 0.005), had more spinal CSF leakage (12.04 vs. 8.04, P = 0.01), and had a higher percentage of dural sinus engorgement (81.63% vs. 60.00%, P = 0.044). Spontaneous intracranial hypotension (odds ratio [OR]: 4.63; 95% confidence interval [CI]: 1.00-21.38) and having ≥9 spinal CSF leakages (OR: 3.29; 95% CI: 1.08-10.01), as indicated by magnetic resonance myelography, are considered risk factors for noneffective hydration. CONCLUSIONS Patients with spinal CSF leakage who have spontaneous intracranial hypotension and those with ≥9 spinal CSF leakages are considered at risk for noneffective hydration. EBP should be considered early in these patients.
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22
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Kawahara T, Arita K, Fujio S, Hanaya R, Atsuchi M, Moinuddin FM, Kamil M, Okada T, Hirano H, Kitamura N, Kanda N, Yamahata H, Yoshimoto K. Dural sac shrinkage signs on magnetic resonance imaging at the thoracic level in spontaneous intracranial hypotension-its clinical significance. Acta Neurochir (Wien) 2021; 163:2685-2694. [PMID: 34415442 DOI: 10.1007/s00701-021-04933-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Spontaneous intracranial hypotension (SIH) is secondary to a cerebrospinal fluid leak at the spinal level without obvious causative events. Several signs on brain and cervical spine magnetic resonance (MR) imaging (MRI) have been associated with SIH but can be equivocal or negative. This retrospective study sought to identify characteristic SIH signs on thoracic spinal MRI. METHODS Cranial and spinal MR images of 27 consecutive patients with classic SIH symptoms, who eventually received epidural autologous blood patches (EBPs), were analyzed. RESULTS The most prevalent findings on T2-weighted MRI at the thoracic level were anterior shift of the spinal cord (96.3%) and dorsal dura mater (81.5%), probably caused by dural sac shrinkage. These dural sac shrinkage signs (DSSS) were frequently accompanied by cerebrospinal fluid collection in the posterior epidural space (77.8%) and a prominent epidural venous plexus (77.8%). These findings disappeared in all six patients who underwent post-EBP spinal MRI. Dural enhancement and brain sagging were minimum or absent on the cranial MR images of seven patients, although DSSS were obvious in these seven patients. For 23 patients with SIH and 28 healthy volunteers, a diagnostic test using thoracic MRI was performed by 13 experts to validate the usefulness of DSSS. The median sensitivity, specificity, positive-predictive value, negative-predictive value, and accuracy of the DSSS were high (range, 0.913-0.931). CONCLUSIONS Detection of DSSS on thoracic MRI facilitates an SIH diagnosis without the use of invasive imaging modalities. The DSSS were positive even in patients in whom classic cranial MRI signs for SIH were equivocal or minimal.
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Affiliation(s)
- Takashi Kawahara
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
- Department of Neurosurgery, Atsuchi Neurosurgical Hospital, Kagoshima, Japan
- Department of Neurosurgery, Kagoshima City Hospital, Kagoshima, Japan
| | - Kazunori Arita
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
- Department of Neurosurgery, Izumi Regional Medical Center, Akune, Japan.
| | - Shingo Fujio
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Ryosuke Hanaya
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Masamichi Atsuchi
- Department of Neurosurgery, Atsuchi Neurosurgical Hospital, Kagoshima, Japan
| | - F M Moinuddin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Muhammad Kamil
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
- Department of Neurologic Surgery, Airlangga University, Surabaya, Indonesia
| | - Tomohisa Okada
- Department of Neurosurgery, Izumi Regional Medical Center, Akune, Japan
| | - Hirofumi Hirano
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Naoyuki Kitamura
- Diagnostic Imaging Center, Medical Network Systems, Hiroshima, Japan
| | - Naoaki Kanda
- Department of Neurology, Imamura General Hospital, Kagoshima, Japan
| | - Hitoshi Yamahata
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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Yücel D. Downregulation of CSF-derived miRNAs miR-142-3p and miR-17-5p may be associated with post-dural puncture headache in pregnant women upon spinal anaesthesia. Braz J Anesthesiol 2021; 72:493-499. [PMID: 34563560 PMCID: PMC9373468 DOI: 10.1016/j.bjane.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/19/2021] [Accepted: 08/28/2021] [Indexed: 11/15/2022] Open
Abstract
Background Postdural puncture headache (PDPH) develops due to puncture of the dura mater. The risk factors that influence PDPH incidence are Body Mass Index (BMI), sex, spinal needle type, history of headache, and loss of Cerebrospinal fluid (CSF) volume, yet there is no consensus on these risk factors. The pathophysiology of PDPH is poorly understood. The molecular pathways that may lead to PDPH are unknown. In this study, CSF – derived microRNAs (miRNAs) were investigated for their potential to predispose to PDPH in a population of pregnant women. Methods Pregnant women going under cesarean section via spinal anesthesia were included in the study with the criteria of the subjects presenting American Society of Anesthesiologists (ASA) physical status I. Patients were classified into two groups as with PDPH (n = 10) and without PDPH (n = 12) based on International Headache Society’s PDPH definition. CSF-derived microRNAs were investigated for their differential expression levels in PDPH patients compared with the healthy controls using microfluidic gene expression platform. Results Out of seventy-six miRNAs, two miRNAs, namely miR-142-3p and miR-17-5p, were significantly downregulated in PDPH patients (Mann-Whitney U test, p < 0,05). BMI and age did not influence PDPH occurrence. The mean visual analogue scale (VAS) of the PDPH patients was 6,8 out of 10. Conclusion We have shown that downregulation of miR-142-3p and miR-17-5p may predispose pregnant women to PDPH upon spinal anesthesia. However, which genes are targeted by miR-142-3p and miR-17-5p-mediated effect on PDPH remains to be elucidated.
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Affiliation(s)
- Duygu Yücel
- Erciyes University, Genome and Stem Cell Center (GenKok), Kayseri, Turkey.
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Lumbar Puncture for Diagnosis of Idiopathic Intracranial Hypertension in Typical Patients. J Neuroophthalmol 2021; 41:375-378. [PMID: 34369470 DOI: 10.1097/wno.0000000000001319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with typical features of pseudotumor cerebri syndrome (PTCS) must undergo lumbar puncture (LP) to demonstrate elevated opening pressure and cerebrospinal fluid (CSF) analysis to rule out alternative diagnoses. As LP may be associated with significant morbidity, this study aims to determine its necessity in diagnosing typical PTCS. METHODS Retrospective chart review at 3 university-based neuro-ophthalmology practices included women aged 18-45 years with body mass index >25, papilledema, negative neuroimaging, and who met criteria for PTCS or probable PTCS. RESULTS One hundred fifty-six patients were enrolled. Seven (4.5%) had clinically insignificant CSF abnormalities. No diagnoses or management changed based on LP/CSF results. CONCLUSION LP may not be routinely required in the initial evaluation of typical patients with PTCS evaluated by experienced clinicians We caution, however, that further prospective study is required to determine potential risks and benefits of LP as a tool in the diagnosis of IIH before recommending general practice changes.
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Tai CS, Wu SL, Lin SY, Liang Y, Wang SJ, Chen SP. The causal-effect of bed rest and post-dural puncture headache in patients receiving diagnostic lumbar puncture: A prospective cohort study. J Chin Med Assoc 2021; 84:791-794. [PMID: 34074932 DOI: 10.1097/jcma.0000000000000562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Post-dural puncture headache (PDPH) is the most common complication of lumbar puncture. Patients who received lumbar puncture were previously suggested to remain in bed for a certain time to prevent PDPH; however, this concept was challenged by recent studies. We aimed to investigate whether ambulation instead of resting supine following lumbar puncture could increase the risk of PDPH. METHODS The study used a prospective cohort design, applying convenience sampling among patients who received diagnostic lumbar puncture between January and September 2018 in the neurology ward of a tertiary medical center. The patients who fulfilled the inclusion criteria were informed that the current practice suggests lying supine for 6 to 8 hours after lumbar puncture, but they were allowed to either follow the suggestion or ambulate by their wills. The timing of bed rest was recorded, in addition to other possible risk factors of PDPH. The study endpoint is the presence or absence of PDPH within 48 hours of lumbar puncture. RESULTS A total of 137 patients who received lumbar puncture were enrolled, including 103 with bed rest following lumbar puncture and 34 without. There was no difference in demographics between the two groups. PDPH was found in 21 patients, with a total follow-up period of 5959 person-hours and an incidence density of 0.35%. There was no significant difference between the incidence of PDPH between the two groups (non-bed rest group 5.9% vs bed rest group 18.4%; p = 0.078), nor was incidence density (non-bed rest group 0.13% vs bed rest group 0.43%, p = 0.113). The results remained the same after adjusting for age. CONCLUSION Bed rest following lumbar puncture does not prevent PDPH, and even leads to a marginally increased risk of PDPH. Amendment to the current practice guideline post-lumbar puncture care might be needed to improve patient care.
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Affiliation(s)
- Chien-Shu Tai
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shang-Liang Wu
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shao-Yu Lin
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ying Liang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Ahmed I, Majeed A, Fernando R, Hyare H, Columb M, Setty T. Magnetic resonance imaging of cerebrospinal fluid spread in the epidural space and postdural puncture headache in obstetrics: A proof-of-concept study. Eur J Anaesthesiol 2021; 38:777-784. [PMID: 33470687 DOI: 10.1097/eja.0000000000001445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Currently, performing an epidural blood patch (EBP) for postdural puncture headache (PDPH) remains a subjective clinical decision. An evidence-based protocol may be of value in identifying women at high risk of developing a severe PDPH. OBJECTIVE To investigate a potential correlation between the extent of CSF spread in the epidural space, as noted on Magnetic Resonance Imaging (MRI), and the likelihood of development of severe PDPH in obstetric patients. DESIGN A prospective double-blind quasi-observational study. SETTING Eight tertiary obstetric units, from NHS hospitals. PATIENTS Parturients with accidental dural puncture (ADP) underwent T1 and T2-weighted MRI scans of the brain and lumbar spine within 48 h after delivery. All women were followed up, daily, for 1 week. MAIN OUTCOME MEASURES For each woman, a PDPH severity score was calculated using a four-point Verbal Reporting Scale (none = 0, mild = 1, moderate = 2, severe = 3), with additional points awarded for visual, auditory and emetic symptoms. MRIs were reported by a neuroradiologist, blind to the patient details, using a predefined MRI score. RESULTS Twenty-two parturients were recruited; 86% (n=19) developed PDPH and 10 of these (53%) required an EBP. The median (range) time for the onset of PDPH was 24 (4 to 126) hours. The median (range) cumulative PDPH severity score was 10 (0 to 21), whereas, the median (range) MRI score was 2.5 (0 to 12). Spearman (rs) analysis identified a significant positive correlation (rs = 0.46; P = 0.024) between cumulative PDPH severity and MRI scores. Of all the radiological features identified in an MRI (lumbar dural shift, caudal brain displacement, epidural or intrathecal blood), the presence of intrathecal blood was most strongly correlated with PDPH severity (P = 0.043). CONCLUSION Following an ADP, the extent of CSF spread in the epidural space correlates with the severity of subsequent PDPH. CLINICAL TRIAL NUMBER AND REGISTRY URL ISRCTN14959004, https://www.isrctn.com/.
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Affiliation(s)
- Iftikhar Ahmed
- From the Department of Anaesthesia, King Faisal Specialist Hospital & Research Centre, Kingdom of Saudi Arabia (IA, AM), Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar (RF), Department of Anaesthesia, University College Hospital, London (HH, TS) and Department of Anaesthesia, University Hospital of South Manchester, Wythenshawe, UK (MC)
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Abstract
PURPOSE OF REVIEW Spontaneous intracranial hypotension is a disorder caused by spinal CSF leakage. This article reviews the clinical presentation, diagnosis, and treatment of spontaneous intracranial hypotension. RECENT FINDINGS The hallmark symptom of spontaneous intracranial hypotension is acute orthostatic headache; however, clinical presentations can be heterogeneous. New evidence shows that lumbar puncture is not always necessary or sufficient to establish the diagnosis. Some patients may have normal opening pressure, which suggests that insufficiency of CSF volume (hypovolemia) rather than CSF pressure might be the underlying mechanism. Several neuroimaging modalities can aid in diagnosis and localization of the CSF leakage, including brain MRI, spinal MRI, CT myelography, digital subtraction myelography, and radionuclide cisternography. Complications, such as subdural hematoma, can lead to a change in the headache pattern and potentially life-threatening consequences. Conservative treatments, such as fluid supplementation, can provide temporary relief; however, epidural blood patches, especially targeted ones, are more effective and definitive. For patients with refractory spontaneous intracranial hypotension, surgical repair of spinal CSF leakages should be considered. SUMMARY Brain and spinal MRIs are important for the diagnosis and treatment of patients with spontaneous intracranial hypotension. Early treatment with epidural blood patches may be considered to shorten the disease duration and minimize the potential risk of complications.
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Osawa I, Kozawa E, Mitsufuji T, Yamamoto T, Araki N, Inoue K, Niitsu M. Intravenous enhanced 3D FLAIR imaging to identify CSF leaks in spontaneous intracranial hypotension: Comparison with MR myelography. Eur J Radiol Open 2021; 8:100352. [PMID: 34026946 PMCID: PMC8134034 DOI: 10.1016/j.ejro.2021.100352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/27/2021] [Accepted: 05/08/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose To evaluate the clinical utility of intravenous gadolinium-enhanced heavily T2-weighted 3D fluid-attenuated inversion recovery (HT2-FLAIR) imaging for identifying spinal cerebrospinal fluid (CSF) leaks in patients with spontaneous intracranial hypotension (SIH). Methods Patients with SIH underwent MR myelography and post-contrast HT2-FLAIR imaging after an intravenous gadolinium injection. Two types of CSF leaks (epidural fluid collection and CSF leaks around the nerve root sleeve) at each vertebral level were compared between the 2 sequences. The total numbers of CSF leaks and vertebral levels involved were recorded for the whole spine. The sequence that was superior for the overall visualization of epidural and paraspinal fluid collection was then selected. Results Nine patients with SIH were included in the present study. HT2-FLAIR imaging was equivalent or superior to MR myelography at each level for detecting the 2 types of CSF leaks. In the 2 types of CSF leaks, the total numbers of CSF leaks and levels involved were higher on HT2-FLAIR images than on MR myelography, while no significant difference was observed for CSF leaks around the nerve root sleeve. In all 9 patients, HT2-FLAIR imaging was superior to MR myelography for the overall visualization of epidural and paraspinal fluid collection. Conclusion Intravenous gadolinium-enhanced HT2-FLAIR imaging was superior to MR myelography for the visualization of CSF leaks in patients with SIH. This method can be useful for identifying spinal CSF leaks.
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Key Words
- CHESS, Chemical shift selective
- CSF, Cerebrospinal fluid
- FLAIR, Fluid-attenuated inversion recovery
- HT2-FLAIR, Heavily T2-weighted fluid-attenuated inversion recovery
- Heavily T2-weighted 3D FLAIR
- Intravenous gadolinium-enhanced MR imaging
- MIP, Maximum intensity projection
- MPR, Multiplanar reconstruction
- MR myelography
- MRI, Magnetic resonance imaging
- SIH, Spontaneous intracranial hypotension
- Spinal cerebrospinal fluid leak
- Spontaneous intracranial hypotension
- T1W, T1-weighted
- T2W, T2-weighted
- TSE, Turbo spin echo
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Affiliation(s)
- Iichiro Osawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
- Corresponding author at: 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan.
| | - Eito Kozawa
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Takashi Mitsufuji
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Toshimasa Yamamoto
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Nobuo Araki
- Department of Neurology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Kaiji Inoue
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
| | - Mamoru Niitsu
- Department of Radiology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
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Yu R, Kale H, Branstetter BF, Palfey S, Agarwal V. Epidural Contrast Volume on Post-Myelogram Lumbar CT Predicts the Rate of Subsequent Blood Patch Treatment. J Neuroimaging 2021; 31:691-695. [PMID: 33877730 DOI: 10.1111/jon.12852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/15/2021] [Accepted: 02/26/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Headaches due to cerebrospinal fluid (CSF) leakage are a well-known complication of dural puncture. The purpose of this study was to determine whether the presence and volume of epidural contrast on postmyelogram CTs of the lumbar spine were associated with post-dural puncture headaches (PDPHs) requiring epidural blood patch (EBP) treatment. METHODS A retrospective case control study of all fluoroscopically guided lumbar myelograms performed over a 5-year period by a single radiology practitioner assistant was performed. Ten patients who underwent EBP treatment after their myelograms were identified. Forty-six patients with similar demographics who did not receive blood patches were then selected. CT-lumbar myelogram images of patients and controls were reviewed. The volume of epidural contrast was then quantified as "severe" or "mild." Severe epidural contrast was defined as contrast detected in the ventral epidural space, the extra-foraminal space, or extending greater than or equal to the length of two vertebral bodies from the level of dural puncture. RESULTS Some amount of epidural contrast was seen in all patients. However, a severe volume of epidural contrast was associated with increased risk for PDPH requiring an EBP (odds ratio = 37.00; 95% CI = 4.1-330.8, p = 0.0012). CONCLUSION Severe epidural contrast on postmyelogram CTs of the lumbar spine was associated with an increased risk of PDPH requiring EBP treatment. When present, this finding can alert the proceduralist that the patient may require closer observation and follow up with earlier intervention.
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Affiliation(s)
- Robinson Yu
- Bay Imaging Consultants Medical Group, Walnut Creek, California, USA
| | - Hrishikesh Kale
- Department of Radiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
| | - Barton F Branstetter
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stacie Palfey
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vikas Agarwal
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Huq S, Iyer MG, Oyibo SO. Delayed diagnosis of bilateral subdural effusions complicating intracranial hypotension in a patient presenting with post lumbar puncture headache. BMJ Case Rep 2021; 14:14/2/e239559. [PMID: 33547096 PMCID: PMC7871253 DOI: 10.1136/bcr-2020-239559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A 34-year-old woman presented with an unrelenting headache which had been ongoing since discharge from hospital 4 days before. She initially presented 2 weeks earlier with a 7 days history of severe headache, for which she had a CT scan, lumbar puncture and treatment for possible viral meningitis. The headache got worse 4 days after the lumbar puncture. Despite analgesics and bed rest, the headache persisted. A subsequent magnetic imaging scan demonstrated bilateral subdural effusions. She was given supportive treatment, which included advice concerning strict bed rest and analgesia. The headache took several months to abate. A third of patients suffer from post lumbar puncture headaches and this should be explained during informed consenting and post procedure. Not all post lumbar puncture headaches are simple headaches. A post lumbar puncture headache continuing for more than 7-14 days after the procedure requires further investigation to exclude life-threatening intracranial complications.
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Affiliation(s)
- Saleheen Huq
- General Medicine, North West Anglia NHS Foundation Trust, Peterborough, Cambridgeshire, UK
| | - Menaka G Iyer
- General Medicine, North West Anglia NHS Foundation Trust, Peterborough, Cambridgeshire, UK
| | - Samson O Oyibo
- Diabetes and Endocrinology, North West Anglia NHS Foundation Trust, Peterborough, Cambridgeshire, UK
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31
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Isung J, Granqvist M, Trepci A, Huang J, Schwieler L, Kierkegaard M, Erhardt S, Jokinen J, Piehl F. Differential effects on blood and cerebrospinal fluid immune protein markers and kynurenine pathway metabolites from aerobic physical exercise in healthy subjects. Sci Rep 2021; 11:1669. [PMID: 33462306 PMCID: PMC7814004 DOI: 10.1038/s41598-021-81306-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/04/2021] [Indexed: 02/01/2023] Open
Abstract
Mounting evidence shows that physical exercise modulates systemic inflammation. However, its effect on cerebrospinal fluid (CSF) immune-marker profiles in man are largely unknown. We here report a study on healthy subjects (n = 27, males = 12, mean age 28.7, range 22-52) allocated to either an acute exercise setting over four consecutive days, or a training intervention over 4 weeks. Paired plasma and CSF samples collected at baseline, after 7 days of exercise abstention, and the day after completion of the exercise interventions, were analyzed for protein inflammation markers using a multiplex proximity extension assay and neurotransmitters and kynurenine pathway (KP) metabolites using liquid chromatography, respectively. Routine cell counts, and albumin, immunoglobulin G and neurofilament light chain concentrations in CSF remained unchanged in both paradigms, while several inflammatory proteins became upregulated after acute exercise. However, only changes in three CSF (vascular endothelial growth factor-A, interleukin-7 and matrix metalloproteinase-10) and 12 plasma proteins reached significance levels after adjustment for multiple comparisons and exclusion of less stable proteins. Similarly, KP metabolites only changed among participants after acute exercise, while neurotransmitter levels, except for increased CSF serine, remained stable. Both in plasma and CSF changes in KP metabolites and inflammatory proteins correlated, suggesting that these processes are functionally linked. These findings suggest that acute aerobic physical exercise affects immune markers and KP metabolites systemically and in the CSF.
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Affiliation(s)
- Josef Isung
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
| | - Mathias Granqvist
- Division of Physiotherapy, Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet, and Academic Specialist Center, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Ada Trepci
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jesse Huang
- Division of Physiotherapy, Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet, and Academic Specialist Center, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Lilly Schwieler
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Marie Kierkegaard
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Academic Specialist Center, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Sophie Erhardt
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jussi Jokinen
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Department of Clinical Sciences, Umeå University, Umeå, Sweden
| | - Fredrik Piehl
- Division of Physiotherapy, Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet, and Academic Specialist Center, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Haugstvedt AF, Havsteen IB, Christensen H. Dural tear from diagnostic lumbar puncture followed by long-term morbidity: a case report. Neurol Res Pract 2020; 2:36. [PMID: 33324936 PMCID: PMC7650130 DOI: 10.1186/s42466-020-00083-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/27/2020] [Indexed: 01/03/2023] Open
Abstract
Background Lumbar punctures are performed in different medical settings and are a key procedure in the diagnosis of several neurological conditions. Complications are rare and generally self-limiting. There are no reports of symptomatic accumulation of fluid in the epidural space after lumbar puncture in adults and there are no studies on long-term outcome after post dural puncture headache (PDPH). Case A lumbar puncture was performed in a 29 y.o. slender woman with unspecific symptoms to rule out neuro-infection. Next day MRI showed substantial accumulation of CSF in the epidural space from C2 to the sacrum dislocating the spinal chord in the spinal canal. The condition was ameliorated by epidural blood-patching. At 5 months she was still impaired by severe orthostatic headache. Conclusions The only plausible explanation for the massive CSF leak was a dural tear occurring during multiple attempts of lumbar puncture. Anterior dislocation of the spinal chord due to CSF leak is not a recognised complication to lumbar puncture. This complication was followed by long-term disability in our case. The diagnosis can be made by MRI. A difficult procedure with several attempts and use of traumatic technique may increase risk of this complication.
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Affiliation(s)
- Aleksander Fjeld Haugstvedt
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Inger Birgitte Havsteen
- Department of Radiology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg and Frederiksberg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark.,Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
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Wu JW, Wang SJ. Is Lower Glucose Level a Risk Factor for Post-Dural Puncture Headache? Headache 2020; 60:1886-1887. [PMID: 32996134 DOI: 10.1111/head.13881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/11/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Jr-Wei Wu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
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Utility of heavily T2-weighted MR myelography as the first step in CSF leak detection and the planning of epidural blood patches. J Clin Neurosci 2020; 77:110-115. [PMID: 32402615 DOI: 10.1016/j.jocn.2020.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/01/2020] [Indexed: 11/22/2022]
Abstract
Heavily T2-weighted MR myelography (HT2W-MRM) is emerging as an alternative approach for detection and follow up of CSF leaks. We aimed to assess epidural blood patch (EBP) treatment outcome when using HT2W-MRM as the primary modality for detecting CSF leak and planning EBP placement in routine clinical practice. Since 2018, patients at our institute suspected of having CSF leak, routinely HT2W-MRM instead of CT myelography to determine presence of the leak and identify the EBP target site. Fifty-nine consecutive patients suspected of having a CSF leak underwent HT2W-MRM. After excluding patients with subdural hematoma and poor image quality, 26 (10 men, 16 women; mean age 44.92 ± 12.6 years) patients were included in this study. Patients received EBP on the basis of HT2W-MRM assessments and clinical assessment. Imaging findings and clinical outcome were evaluated. CSF leak was identified in 21 patients (80.8%, 21/26) based HT2W-MRM. Most cases were graded on a confidence scale as CSF leak definitely (n = 13) or probably (n = 3) present. Successful clinical EBP treatment was achieved in 14 of 17 patients (82.4%) after first targeted EBP, and patient symptoms significantly improved after treatment (numerical rating score 6.4 before EBP, 1.3 after EBP, P < 0.001). HT2W-MRM based EBP are the rational and effective choices for CSF leak treatment in routine clinical practice.
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Gandhi J, DiMatteo A, Joshi G, Smith NL, Khan SA. Cerebrospinal fluid leaks secondary to dural tears: a review of etiology, clinical evaluation, and management. Int J Neurosci 2020; 131:689-695. [PMID: 32242448 DOI: 10.1080/00207454.2020.1751625] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Damage to the dura mater often occurs in trauma cases of the head and spine, surgical procedures, lumbar punctures, and meningeal diseases. The resulting damage from dural tears, or durotomy, causes cerebrospinal fluid (CSF) to leak out into the surrounding space. The CSF leak induces intracranial hypotension, which can clinically present with a range of symptoms not limited to positional headaches which can confound accurate diagnosis. Current methods of evaluation and management of dural tears are discussed herewith, as well as the present understanding of its etiology, which may be classified as related to surgery, procedure, trauma, or connective tissue disorder. METHODS We piloted a MEDLINE® database search of literature, with emphasis on the previous five years, combining keywords such as "cerebrospinal fluid leak," "surgery," "procedure," and "trauma" to yield original research articles and case reports for building a clinical profile. RESULTS Patients with suspected dural tears should be evaluated based on criteria set by the International Headache Society, radiological findings, and a differential diagnosis to accurately identify the tear and its potential secondary complications. Afflicted patients may be treated promptly with epidural blood patches, epidural infusions, epidural fibrin glue, or surgical repair. At this time, epidural blood patches are the first line of treatment. Dural tears can be prevented to an extent by utilizing minimally invasive techniques and certain positions for lumbar puncture. Surgical, trauma, lumbar puncture, and epidural injection patients should be observed very carefully for dural tears and CSF leaks as the presenting clinical manifestations can be highly individualized and misguiding. CONCLUSION Because studies have demonstrated a high frequency of dural tears, particularly in spinal surgery patients, there is a need for prospective studies so that clinicians can develop an elaborate prevention strategy and response to avoid serious, unseen complications.
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Affiliation(s)
- Jason Gandhi
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.,Medical Student Research Institute, St. George's University School of Medicine, Grenada, West Indies
| | - Andrew DiMatteo
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Gunjan Joshi
- Department of Internal Medicine, Stony Brook Southampton Hospital, Southampton, NY, USA
| | | | - Sardar Ali Khan
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.,Department of Urology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
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36
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Armstrong SA, Nguyen HTN, Rebsamen SL, Iskandar B, Stadler JA. Epidural Fibrin Sealant Injection for the Management of Cerebrospinal Fluid Leak Following Dural Puncture in Children. Cureus 2020; 12:e6940. [PMID: 32190492 PMCID: PMC7067364 DOI: 10.7759/cureus.6940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cerebrospinal fluid (CSF) leak, intracranial hypotension, and postdural puncture headaches are common following dural punctures. Management usually consists of conservative treatments with medications (e.g. caffeine, nonsteroidal anti-inflammatory drugs, steroids, opioids), increased fluid intake, and bed rest. In more severe and persistent cases, epidural blood patches (EBPs) are indicated. When multiple EBPs fail, epidural injection of fibrin sealant has been successful in a few reported adult cases. The authors describe the first reported clinical experiences of epidural fibrin patch in children for repair of CSF leak and resolution of intracranial hypotension. This technique was used in three cases where serial EBPs failed to resolve symptoms related to intracranial hypotension following dural puncture. Following the procedure, each patient had resolution of their presenting clinical symptoms and radiographic abnormalities, and there were no noted complications. Epidural fibrin sealant injection is a reasonable option for relieving intracranial hypotension due to CSF leak following dural puncture in children.
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Affiliation(s)
- Stephanie A Armstrong
- Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Huy Tram N Nguyen
- Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Susan L Rebsamen
- Radiology, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Bermans Iskandar
- Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - James A Stadler
- Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, USA
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Kenny A, McArdle H, Calero M, Rabano A, Madden SF, Adamson K, Forster R, Spain E, Prehn JHM, Henshall DC, Medina M, Jimenez-Mateos EM, Engel T. Elevated Plasma microRNA-206 Levels Predict Cognitive Decline and Progression to Dementia from Mild Cognitive Impairment. Biomolecules 2019; 9:biom9110734. [PMID: 31766231 PMCID: PMC6920950 DOI: 10.3390/biom9110734] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/31/2019] [Accepted: 11/09/2019] [Indexed: 02/06/2023] Open
Abstract
The need for practical biomarkers for early diagnosis of Alzheimer’s disease (AD) remains largely unmet. Here we investigated the use of blood-based microRNAs as prognostic biomarkers for AD and their application in a novel electrochemical microfluidic device for microRNA detection. MicroRNA transcriptome was profiled in plasma from patients with mild cognitive impairment (MCI) and AD. MicroRNAs Let-7b and microRNA-206 were validated at elevated levels in MCI and AD, respectively. MicroRNA-206 displayed a strong correlation with cognitive decline and memory deficits. Longitudinal follow-ups over five years identified microRNA-206 increases preceding the onset of dementia. MicroRNA-206 was increased in unprocessed plasma of AD and MCI subjects, detected by our microfluidic device. While increased Let-7b levels in plasma may be used to identify patients with MCI, changes in plasma levels of microRNA-206 may be used to predict cognitive decline and progression towards dementia at an MCI stage. MicroRNA quantification via a microfluidic device could provide a practical cost-effective tool for the stratification of patients with MCI according to risk of developing AD.
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Affiliation(s)
- Aidan Kenny
- Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin D02 YN77, Ireland; (A.K.); (D.C.H.)
| | - Hazel McArdle
- School of Chemical Sciences, Dublin City University, Dublin 9, Ireland; (H.M.); (K.A.); (E.S.)
| | - Miguel Calero
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), 28031 Madrid, Spain; (M.C.); (A.R.); (M.M.)
- Carlos III Institute of Health, 28220 Madrid, Spain
| | - Alberto Rabano
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), 28031 Madrid, Spain; (M.C.); (A.R.); (M.M.)
- Centro de Investigación en Enfermedades Neurológicas (CIEN) Foundation, Queen Sofia Foundation Alzheimer Center, 28031 Madrid, Spain
| | - Stephen F. Madden
- Data Science Centre, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland;
| | - Kellie Adamson
- School of Chemical Sciences, Dublin City University, Dublin 9, Ireland; (H.M.); (K.A.); (E.S.)
| | - Robert Forster
- School of Chemical Sciences, National Centre for Sensor Research, Dublin City University, Dublin 9, Ireland;
- FutureNeuro SFI Research Centre, Dublin D02 YN77, Ireland
| | - Elaine Spain
- School of Chemical Sciences, Dublin City University, Dublin 9, Ireland; (H.M.); (K.A.); (E.S.)
| | - Jochen H. M. Prehn
- Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin D02 YN77, Ireland; (A.K.); (D.C.H.)
- FutureNeuro SFI Research Centre, Dublin D02 YN77, Ireland
| | - David C. Henshall
- Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin D02 YN77, Ireland; (A.K.); (D.C.H.)
- FutureNeuro SFI Research Centre, Dublin D02 YN77, Ireland
| | - Miguel Medina
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), 28031 Madrid, Spain; (M.C.); (A.R.); (M.M.)
- Centro de Investigación en Enfermedades Neurológicas (CIEN) Foundation, Queen Sofia Foundation Alzheimer Center, 28031 Madrid, Spain
| | - Eva M. Jimenez-Mateos
- Discipline of Physiology, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin D02 PN40, Ireland
- Correspondence: (E.M.J.-M.); (T.E.); Tel.: +35318965199 (E.M.J.-M.); +35314025199 (T.E.); Fax: +35314022447 (T.E.)
| | - Tobias Engel
- Department of Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin D02 YN77, Ireland; (A.K.); (D.C.H.)
- FutureNeuro SFI Research Centre, Dublin D02 YN77, Ireland
- Correspondence: (E.M.J.-M.); (T.E.); Tel.: +35318965199 (E.M.J.-M.); +35314025199 (T.E.); Fax: +35314022447 (T.E.)
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Smith JH, Mac Grory B, Butterfield RJ, Khokar B, Falk BL, Marks LA. CSF Pressure, Volume, and Post‐Dural Puncture Headache: A Case‐Control Study and Systematic Review. Headache 2019; 59:1324-1338. [DOI: 10.1111/head.13602] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2019] [Indexed: 12/14/2022]
Affiliation(s)
| | | | | | - Babar Khokar
- Department of Neurology Yale University New Haven CT USA
| | - Bryce L. Falk
- Department of Neurology Mayo Clinic Scottsdale AZ USA
| | - Lisa A. Marks
- Department of Library Services Mayo Clinic Scottsdale AZ USA
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Russell R, Laxton C, Lucas DN, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch. Int J Obstet Anesth 2019; 38:104-118. [PMID: 30711239 DOI: 10.1016/j.ijoa.2018.12.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/12/2018] [Accepted: 12/16/2018] [Indexed: 12/31/2022]
Abstract
The 2009-12 MBRRACE-UK report highlighted the deaths of two women in whom dural puncture had occurred during insertion of a labour epidural catheter. Despite suffering long-term headaches, neither woman was adequately followed-up after discharge from hospital. Death resulted from a cerebral vein thrombosis in one case and a subdural haematoma in the other. Due to significant variation in the treatment of obstetric post-dural puncture headache, an Obstetric Anaesthetists' Association working group was set up to produce evidence-based guidelines to guide clinicians. These guidelines have been condensed into two review articles. In this second review, the role of an epidural blood patch is discussed using a question and answer format.
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Affiliation(s)
- R Russell
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - C Laxton
- Department of Anaesthetics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D N Lucas
- Department of Anaesthetics, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - J Niewiarowski
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Scrutton
- Department of Anaesthetics, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - G Stocks
- Department of Anaesthetics, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
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Hu B, Chen TM, Liu B, Chi W, Miao YQ, Nie XL, Peng XX, Liu G. Optimal management after paediatric lumbar puncture: a randomized controlled trial. BMC Neurol 2019; 19:64. [PMID: 30987603 PMCID: PMC6466704 DOI: 10.1186/s12883-019-1275-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 03/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate whether a shorter time of lying supine without a pillow and fasting for solids and liquids (LSFSL) after a lumbar puncture (LP) is associated with a higher risk of post-lumbar puncture headache (PLPH) and post-lumbar puncture lower back pain (PLPBP) in a randomized, assessor-blinded, controlled trial. METHODS Paediatric patients who underwent their first LP after hospital admission were randomly allocated to either the group with half an hour of LSFSL (0.5 h LSFSL) or 4 h of LSFSL (4 h LSFSL) immediately after LP. The primary outcome is PLPH after LP. The incidence of PLPH, PLPBP, and vomiting; vital signs (respiratory rate, heart rate, blood pressure); and other post-procedure conditions after LP were measured as the outcomes. The Non-inferiority test and Wilcoxon rank-sum test were used to analyse the outcome data. RESULTS In total, 400 patients (201 in the 0.5-h LSFSL group and 199 in the 4-h LSFSL group) were included in this trial. Twelve (5.97%) of 201 patients experienced PLPH in the 0.5 h LSFSL group versus 13 (6.53%) of 199 patients in the 4 h LSFSL group (difference 0.56, 95% CI -4.18 to 5.31; p = 0·0108 for the non-inferiority test). Fourteen (6.97%) of 201 patients experienced PLPBP in the 0.5 h LSFSL group versus 17 (8.54%) of 199 patients in the 4 h LSFSL group (difference 1.57, 95% CI -3.66 to 6.82; p = 0.007 for the non-inferiority test). The changes in heart rate (HR), respiratory rate (RP) and systolic blood pressure (SBP) before and after the LP were not different between the 0.5-h LSFSL group and the 4-h LSFSL group. No other adverse events were reported. CONCLUSIONS Compared with 4 h of LSFSL after LP, 0.5 h of LSFSL was not associated with a higher risk of PLPH, PLPBP or other adverse events. In conclusion, 0.5 h of LSFSL is sufficient for children undergoing LP. TRIAL REGISTRATION Clinical trial NCT02590718 . The date of registration was 08/25/2015.
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Affiliation(s)
- Bing Hu
- Department of Infectious Diseases, Beijing Children’s Hospital, Capital Medical University, Nalishi Road 56#, Xicheng District, Beijing, 100045 China
| | - Tian-ming Chen
- Department of Infectious Diseases, Beijing Children’s Hospital, Capital Medical University, Nalishi Road 56#, Xicheng District, Beijing, 100045 China
| | - Bing Liu
- Department of Infectious Diseases, Beijing Children’s Hospital, Capital Medical University, Nalishi Road 56#, Xicheng District, Beijing, 100045 China
| | - Wei Chi
- Department of Infectious Diseases, Beijing Children’s Hospital, Capital Medical University, Nalishi Road 56#, Xicheng District, Beijing, 100045 China
| | - Yi-qing Miao
- Department of Infectious Diseases, Beijing Children’s Hospital, Capital Medical University, Nalishi Road 56#, Xicheng District, Beijing, 100045 China
| | - Xiao-lu Nie
- Center for Clinical Epidemiology and Evidence-based Medicine, Beijing Children’s Hospital, Capital Medical University, Nalishi Road 56#, Xicheng District, Beijing, 100045 China
| | - Xiao-xia Peng
- Center for Clinical Epidemiology and Evidence-based Medicine, Beijing Children’s Hospital, Capital Medical University, Nalishi Road 56#, Xicheng District, Beijing, 100045 China
| | - Gang Liu
- Department of Infectious Diseases, Beijing Children’s Hospital, Capital Medical University, Nalishi Road 56#, Xicheng District, Beijing, 100045 China
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Wu JW, Wang YF, Fuh JL, Lirng JF, Chen SP, Hseu SS, Wang SJ. Correlations among brain and spinal MRI findings in spontaneous intracranial hypotension. Cephalalgia 2018; 38:1998-2005. [DOI: 10.1177/0333102418804161] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Several brain and spinal magnetic resonance imaging signs have been described in spontaneous intracranial hypotension. Their correlations are not fully studied. This study aimed to explore potential mechanisms underlying cerebral neuroimaging findings and to examine associations among spinal and brain magnetic resonance imaging signs. Methods We conducted a retrospective review of magnetic resonance myelography and brain magnetic resonance imaging records of patients with spontaneous intracranial hypotension. Categorical principal component analysis was employed to cluster brain neuroimaging findings. Spearman correlation was employed to analyze associations among different brain neuroimaging findings and between brain and spinal neuroimaging findings. Results In patients with spontaneous intracranial hypotension (n = 148), categorical principal component analysis of brain neuroimaging signs revealed two clusters: Cerebral venous dilation and brain descent. Among all brain magnetic resonance imaging signs examined, only midbrain-pons angle associated with anterior epidural cerebrospinal fluid collection length (surrogate spinal cerebrospinal fluid leak severity) (n = 148, Spearman’s ρ = −0.38, p < .001). Subgroup analyses showed that the association between midbrain-pons angle (within brain descent cluster) and spinal cerebrospinal fluid leak severity was presented in patients with convex margins of the transverse sinuses (n = 122, Spearman’s ρ = −0.43, p < .001), but not in patients without convex margins (n = 26, Spearman’s ρ = −0.19, p = .348). The association between severity of transverse sinus distension and spinal cerebrospinal fluid leak severity was only presented in patients without convex margins (n = 26, Spearman’s ρ = 0.52, p = .006). Conclusion This study indicates that there are two factors behind the brain neuroimaging findings in spontaneous intracranial hypotension: Cerebral venous dilation and brain descent. Certain brain neuroimaging signs correlate with spinal cerebrospinal fluid leakage severity, depending on different circumstances.
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Affiliation(s)
- Jr-Wei Wu
- Department of Neurology, Taipei City Hospital, Taipei City, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei City, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei City, Taiwan
| | - Jiing-Feng Lirng
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei City, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei City, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei City, Taiwan
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Shu-Shya Hseu
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei City, Taiwan
- Department of Anaesthesiology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei City, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei City, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei City, Taiwan
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Li J, Li X, Tong X, Liu J, Huang B, Chen M, Kuang L, Zhou Z, Xu D. Investigation of the optimal duration of bed rest in the supine position to reduce complications after lumbar puncture combined with intrathecal chemotherapy: a multicenter prospective randomized controlled trial. Support Care Cancer 2018; 26:2995-3002. [PMID: 29546527 PMCID: PMC6096529 DOI: 10.1007/s00520-018-4142-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 03/02/2018] [Indexed: 11/28/2022]
Abstract
Purpose This randomized, open-label trial was conducted to investigate the optimal duration of bed rest after intrathecal chemotherapy to reduce the incidence of complications without increasing patients’ tolerance to long-term bed rest. Methods A total of 390 patients receiving intrathecal chemotherapy were randomly assigned 1:1:1 to undergo bed rest for 6, 8, or 10 h after intrathecal chemotherapy. The primary outcome was the rate of complications after intrathecal chemotherapy. The analysis was per protocol. Results A total of 359 patients among the 390 patients in our study completed follow-up with 120 patients in the 6-h group, 120 in the 8-h group, and 119 in the 10-h group. The complications among the three groups differed significantly (P = 0.005). The 6-h group had significantly more complications than the 8- (50, 41.7% vs 29, 24.2%, P = 0.004) and 10-h groups (50, 41.7% vs 31, 26.1%, P = 0.011), whereas the difference between the 8- and 10-h groups was not significant (29, 24.2% vs 31, 26.1%, P = 0.737). Conclusions The overall results support that the optimal time interval for bed rest in the supine position after intrathecal chemotherapy is 8 h. This trial is registered with the Chinese Clinical Trial Registry (number ChiCTR-IOR-17011671).
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Affiliation(s)
- Juan Li
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510000, China.
| | - Xiaozhe Li
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510000, China
| | - Xiuzhen Tong
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510000, China
| | - Junru Liu
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510000, China
| | - Beihui Huang
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510000, China
| | - Meilan Chen
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510000, China
| | - Lifen Kuang
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510000, China
| | - Zhenhai Zhou
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510000, China
| | - Duorong Xu
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510000, China
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Singla A, Yang S, Werner BC, Cancienne JM, Nourbakhsh A, Shimer AL, Hassanzadeh H, Shen FH. The impact of preoperative epidural injections on postoperative infection in lumbar fusion surgery. J Neurosurg Spine 2017; 26:645-649. [DOI: 10.3171/2016.9.spine16484] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVELumbar epidural steroid injections (LESIs) are performed for both diagnostic and therapeutic purposes for a variety of indications, including low-back pain, the leading cause of disability and expense due to work-related conditions in the US. The steroid agent used in epidural injections is reported to relieve nerve root inflammation, local ischemia, and resultant pain, but the injection may also have an adverse impact on spinal surgery performed thereafter. In particular, the possibility that preoperative epidural injections may increase the risk of surgical site infection after lumbar spinal fusion has been reported but has not been studied in detail. The goal of the present study was to use a large national insurance database to analyze the association of preoperative LESIs with surgical site infection after lumbar spinal fusion.METHODSA nationwide insurance database of patient records was used for this retrospective analysis. Current Procedural Terminology codes were used to query the database for patients who had undergone LESI and 1- or 2-level lumbar posterior spinal fusion procedures. The rate of postoperative infection after 1- or 2-level posterior spinal fusion was analyzed. These study patients were then divided into 3 separate cohorts: 1) lumbar spinal fusion performed within 1 month after LESI, 2) fusion performed between 1 and 3 months after LESI, and 3) fusion performed between 3 and 6 months after LESI. The study patients were compared with a control cohort of patients who underwent lumbar fusion without previous LESI.RESULTSThe overall 3-month infection rate after lumbar spinal fusion procedure was 1.6% (1411 of 88,540 patients). The infection risk increased in patients who received LESI within 1 month (OR 2.6, p < 0.0001) or 1–3 months (OR 1.4, p = 0.0002) prior to surgery compared with controls. The infection risk was not significantly different from controls in patients who underwent lumbar fusion more than 3 months after LESI.CONCLUSIONSLumbar spinal fusion performed within 3 months after LESI may be associated with an increased rate of postoperative infection. This association was not found when lumbar fusion was performed more than 3 months after LESI.
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Affiliation(s)
- Anuj Singla
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Scott Yang
- 2Children's Orthopaedic Center, Children's Hospital Los Angeles, California
| | - Brian C. Werner
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Jourdan M. Cancienne
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ali Nourbakhsh
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Adam L. Shimer
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Hamid Hassanzadeh
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Francis H. Shen
- 1Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia; and
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Sakurai K, Kanoto M, Nakagawa M, Shimohira M, Tokumaru AM, Kameyama M, Shimoji K, Morimoto S, Matsukawa N, Nishio M, Shibamoto Y. Dinosaur Tail Sign: A Useful Spinal MRI Finding Indicative of Cerebrospinal Fluid Leakage. Headache 2017; 57:917-925. [PMID: 28419438 DOI: 10.1111/head.13075] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 02/27/2017] [Accepted: 02/27/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate the imaging characteristics and diagnostic utility of the "Dinosaur tail sign" in the diagnosis of cerebrospinal fluid (CSF) leakage. BACKGROUND The authors propose the "Dinosaur tail sign," defined as a combination of the dorsal epidural hyperintensities, fat tissue, spinal cord, and cauda equine on lumbosacral sagittal fat-suppressed T2-weighted image (FST2WI), as a sensitive indicator for diagnosing CSF leakage. METHODS Imaging characteristics of the "Dinosaur tail sign" was evaluated in seven spontaneous intracranial hypotension (SIH) and 23 iatrogenic CSF leakage (ICSFL) patients. Additionally, the diagnostic index was compared between the "Dinosaur tail sign" and other previously reported useful magnetic resonance imaging (MRI) and magnetic resonance myelography (MRM) findings. RESULTS In contrast to other imaging findings including the epidural expansion, floating dural sac sign, and distension of the spinal epidural veins on MRI, and paraspinal fluid collections (PFC) on MRM, the "Dinosaur tail sign" was found equally in both SIH and ICSFL patients (6 SIH and 19 ICSFL; 83% of all patients with CSF leakage). The "Dinosaur tail sign" showed sufficient diagnostic utility (sensitivity 83%, specificity 94%, accuracy 89%) that was comparable to that of PFC. CONCLUSION The "Dinosaur tail sign" is a useful imaging finding suggestive of CSF leakage. Evaluation of subtle interspinous arched hyperintensities on spinal MRI is mandatory for the diagnosis of SIH and ICSFL.
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Affiliation(s)
- Keita Sakurai
- Department of Diagnostic Radiology, Tokyo Metropolitan Medical Center of Gerontology, Tokyo, Japan
| | - Masafumi Kanoto
- Department of Diagnostic Radiology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Motoo Nakagawa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masashi Shimohira
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Aya M Tokumaru
- Department of Diagnostic Radiology, Tokyo Metropolitan Medical Center of Gerontology, Tokyo, Japan
| | - Masashi Kameyama
- Department of Diagnostic Radiology, Tokyo Metropolitan Medical Center of Gerontology, Tokyo, Japan
| | - Keigo Shimoji
- Department of Diagnostic Radiology, Tokyo Metropolitan Medical Center of Gerontology, Tokyo, Japan
| | - Satoru Morimoto
- Department of Neurology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Noriyuki Matsukawa
- Department of Neurology and Neuroscience, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Abstract
Headache after dural puncture is a common complication accompanying neuraxial anesthesia. The proposed cause is loss of cerebrospinal fluid through the puncture into the epidural space. Although obstetric patients are at risk for the development of this headache because of female gender and young age, there is a difference in the obstetric population. Women who deliver by cesarean delivery have a lower incidence of headache after dural puncture compared with those who deliver vaginally. Treatment of postdural puncture headache is an epidural blood patch. Departments should develop protocols for management of accidental dural puncture, including appropriate follow-up and indications for further management.
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Affiliation(s)
- Robert R Gaiser
- Department of Anesthesiology, University of Kentucky, Lexington, KY 40506, USA.
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Schievink WI, Maya MM, Moser FG. Digital subtraction myelography in the investigation of post–dural puncture headache in 27 patients: technical note. J Neurosurg Spine 2017; 26:760-764. [DOI: 10.3171/2016.11.spine16968] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVEPost–dural puncture headaches are common, and the treatment of such headaches can be complex when they become chronic. Among patients with spontaneous spinal CSF leaks, digital subtraction myelography (DSM) can localize the exact site of the leak when an extradural CSF collection is present, and it can also demonstrate CSF-venous fistulas in those without an extradural CSF collection. The authors now report on the use of DSM in the management of patients with chronic post–dural puncture headaches.METHODSThe patient population consisted of a consecutive group of 27 patients with recalcitrant post–dural puncture headache that had lasted from 2 to 150 months (mean 26 months).RESULTSThe mean age of the 17 women and 10 men was 39.1 years (range 18–77 years). An extensive extradural CSF collection was present in 5 of the 27 patients, and DSM was able to localize the exact site of the dural defect in all 5 patients. Among the 22 patients who did not have an extradural CSF collection, DSM showed a CSF-venous fistula in 1 patient (5%). Three other patients had a small pseudomeningocele at the level of the dural puncture. Percutaneous glue injection or microsurgical repair resulted in resolution of symptoms in 8 of the 9 patients in whom an abnormality had been identified on imaging.CONCLUSIONSDigital subtraction myelography is able to precisely localize the dural puncture site in patients with a post–dural puncture headache and an extensive extradural CSF collection, and it may rarely detect a CSF-venous fistula in such patients without an extradural CSF collection.
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Affiliation(s)
| | - M. Marcel Maya
- 2Radiology, Cedars-Sinai Medical Center, Los Angeles, California
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Wu JW, Hseu SS, Fuh JL, Lirng JF, Wang YF, Chen WT, Chen SP, Wang SJ. Factors predicting response to the first epidural blood patch in spontaneous intracranial hypotension. Brain 2017; 140:344-352. [DOI: 10.1093/brain/aww328] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/08/2016] [Accepted: 10/31/2016] [Indexed: 01/03/2023] Open
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Lin SF, Weng HY. Postural Headaches Due to Cerebrospinal Fluid Leakage Through Subarachnoid-Pleural Fistula: A Case Report. Headache 2016; 57:467-471. [DOI: 10.1111/head.12974] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 01/11/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Sheng-Feng Lin
- Department of Neurology; Wan Fang Hospital, Taipei Medical University; Taipei Taiwan
| | - Hsing-Yu Weng
- Department of Neurology; School of Medicine, College of Medicine, Taipei Medical University; Taipei Taiwan
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Affiliation(s)
- Lou Brundin
- Neuroimmunology, Department of Clinical Neuroscience, Karolinska Institutet, R3:04, Karolinska University Hospital, Stockholm, Sweden
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